Dear Mr Re: Christine Ann WILLIAMSON (deceased) Inquest at Telford Registry Office on 16th December 2013 The Council's Action Plan following Regulation 28 report; to prevent future deaths refer to your letter of 18th December 2013. Following the above Inquest and the Council's receipt of your Report under Regulation 28, we have compiled a plan of action; which is submitted to you as directed, along with this letter: The planned actions_ most_of_which are already well under way to implementation; build upon those recommended by in his Domestic Homicide Review report, which was available to the Inquest The pan was drafted by senior representatives of the Councils Adult Assessment and Case Management; Adult Safeguarding and Community Cohesion services, and endorsed at a meeting of the Senior Management Team on Monday 3rd February 2014. Going forward, it has been agreed that the implementation of the action plan will be formally monitored by the Safeguarding Adults Board for Shropshire and Telford & Wrekin, in pursuance of its remit as the body which brings together all the organisations within the local adult safeguarding partnership trust that this meets with your approval:

Dear Mr Re: Christine Ann WILLIAMSON deceased Inquest: Telford Register Office; 16th December 2013 at 1Oam Report to prevent future deaths Thank you for your letter of the 18th December 2013 under Regulation 28 (Report to Prevent Future Deaths) of the Coroners (Investigations) Regulations 2013. As you will be aware , the Clinical Commission Group actively participated in the Domestic HomicideReviewcommissioned by Telford & Wrekin Safer Community Partnership led by Within the review are 8 recommendations for future learning and action by all agencies involved in Mrs Williamson's care_ This Clinical Commission Group has taken this seriously and has agreed to work with all agencies to prevent future deaths_ As NHS England now commission Primary Care Service the CCG is working with colleagues to address the recommendations The actions we have taken are as follows:
1) The Adult Safeguarding Policy and Thresholds has been recirculated to all GP Practices in Telford & Wrekin to raise awareness of this guidance.
2) Domestic abuse leaflets and guidance has been circulated to all GP Practices. con't. TAKING CARE OF TELFORD AND WREKIN patient experience matters - Every clinician is involved Ellery 3rd Ellery , very Every

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3) An education and training event for all Telford & Wrekin GPs and Practice Nurses will be funded and delivered with a focus on safeguarding requirements and domestic abuse. have written to all GPs to request full attendance as far as possible This event is part of the CCG's Protected Learning Time Programme and will be delivered on 14th May. The training will be multi agency and we have invited the Domestic Abuse Team to present to the attendees ensuring that Royal College of General Practitioner's Guidance is fully referenced in accordance with the DHR recommendations In addition, the CCG Lead Nurse for Adult Safeguarding has established a link with the Admiral Nurses to ensure that referrals figures are monitored. The Admiral Nurses will be invited to the education event to talk to GPs and Practice Nurses about their service, therefore promoting improved understanding for future patients_ Furthermore; the CCG Safeguarding Team has a programme of audit for primary care providers in relation to safeguarding compliance, and this years review is currently underway. In order to address future issues around the growing prevalence of dementia the CCG has in place a dementia strategy which focuses on provision of health services will be delivered, The plan is for a report on all recommendations from the domestic homicide review to be discussed at the Safeguarding Adults Board in June and the CCG Executive Nurse is a member of this Board. This safeguarding is regularly discussed with the CCG and its governing body trust this gives the necessary level of assurance and commitment in this matter;

ive Services Report Prepared for: Title: Coroner Ellery's letter Christine WILLIAMSON (deceased) Prepared by: TIDetective Chief Inspector PVP Introduction This report seeks to Provide a detailed response to Coroner Ellery's letter to West Mereia Police dated 18.12.,13 West Mercia has a duty to respond by 12.02214E znderparagraph 7, schedule 5 of the Coroners & Justice Act 2009 and regulations 28 & 29 of Coroners (Investigations) Regulations 2013. The inquest concerning Mrs Williamson commenced on 13lh November 2012 and concluded on 16uh December 2013. The conclusion of the inquest was 'the deceased died her husband who by reason of his lack of mental physical assault from actions capacity was unaware of his or its consequences If earlier action had been taken the deceased have been protected and death preventable'. may Background Information Mrs Williamson was 62 years old when she died on 318t October 2012, assault upon her by her husband who was suffering advanced following an Alzheimers dementia. The medical causes 0-deathMWaor detevmiced onsebal haematoma following mild blunt head trauma: as subdural ras unaware of his actions and was removed from the family home Unit anceober 2012 following the incident He was admitted to a local Psychiatrie Unit and was subsequently sectioned under Section 3 of the Mental Healttyaca
1983. In September 2013, the Crown Prosecution Sewice made decision that further action would be taken against due to his medical no Plans are being made to move him to a secure hospital condition_ Saeto Fhetcircumstances surrounding this incident Telford and Wrekin Community Sapointeartnership deemed ? Domestic Homicide Review (DHR) approprate andt appointed Jas the independent chair, from her from the

DHR CheneoReviendependent Management Review (IMR) was conducted Crime Review Team (MCRT) It was estableshed that by Major contacts regarding the Williamson West Mercia Police had three between July and October 2012. Contact 1 8th July 2012 Police received a call from Shropdoc (out of hours address following a report of an assaul; GP) who were attending the checks were conducted with no risk ~requesting a police escort: Intelligence factors identified. As a result the decision was taken in officers to the incidenoaw aWakenowronatreon with Shropdoc not to deploy address and attendance that there was a dementia suffer at the aggravate the situation. SCRT concluded that attendance was required in these submission of a crime report for the circumstances, with As this information had not been alleged assault and vulnerable adult incident attending any similar recorded it could not be readily available to seaff incident at a later date. Contact 2 1gth August 2012 Police received & call from a neighbour reporting that could betheard from the address Staff screaming and was a former police staff attended and established that whether WMP member and made enquires to ascertain occupational health would be able to offer any assistanse vulnerable adult incident was submitted but vulnerable adult report no DASH risk assessment: The recorded her [highlighted the Violence suffered by Mrs Williamson;hne 'respecateler eqoring assisar complaints, described her as 'tearfui and requiring assistance MCRT concluded thata DASH risk assessment omission was minimised as the was required however this Protecting Vulnerable People evilnerable adult incident was actioned by crianetherablnbe?pleaenotbeen reterring to Adult Social Servicesin a identified as a repeat incident, not been recorded adequately contact 2 was not Contact 3 ~ 18th October 2012 pushindlinersontcontacied police reporting that her husband had pushing her to the ground iumping povheg assaulted her by horse. this event back and riding her as if she was a hit his wife about the head. Officers attended and witnessed ambulance was called checked lin an agitated manic state The hospital where he has Mrs Williamson and transported to complaint of assault remained since. Mrs Williamson refused to make a formall to that effect)aand refaged €0 bertakebaod (she signed an officers pocket noe bok to be taken to hospital for a more thorough examination_ MCRT concluded that force policy was followed in of all requirements_ incident with the completion the family may the shouting the timely During this

Coroners Matters_of Concern During the inquest Coroner raised concerns that there was a risk future deaths wilzoccur unless action was taken: The matters are detailed in section 5 of his letter:
1. A referral and assessment could have been made before or after April 2012, but most notably on or around 2nd 4th April 2012 when the deceased GP made a direct referral to social services_ This gatter was not reported to Police; The first contact with the Williamson family was &lh July 2012. Evidence Was heard at the inquest suggesting thatthe Gpanas aware of domestic Violence since December 2011, where bruising to Mrs Williamson was photographed at the surgery. 2 Had such an earlier assessment as a vulnerable adult been made then discussions would have taken place with all concerned with everyone significant information sharing it with others The earliest opportunity for Police to have made any referral to partner agencies was 8th 2012; however this was not completed until the second interaction on 19th August 2012. 3_ The DHR recommendations are endorsed. DHR Recommendations and West Mercia Police Response The DHR did not make any specific recommendations for West Mercia Police There are four 'All Agency' recommendations; Recommendation 1 Risk Assessments AII Agencies must review their assessment and management of risk for service users, their carers and significant others in their guidance for staff and provide an analysis of its effectiveness and how it is being monitored . Response: This recommendation does not appear to be wholly relevant to West rercia Police Risk Management Plans are used pro-actively to eiectively manage risk, overseen by supervisors to ensure focus is maintained Recommendation 6 _ Domestic Violence AIl agencies must ensure that there are improvements in service responses for all domestic violence victims (both adults and children), all relevant staff to attend multi-agency training programme based on the DASH model: Response: This recommendation is not relevant to West Mercia Police as all operational staff are trained in the DASH risk assessment process There are policies and procedures in place to guide staff and the DASH risk assessment process is utilised. This process Is regularly audited by the Business Assurance the having July

Team with appropriate learning disseminated to staff. A reminder regarding the requirement to complete DASH; Crime Reports and Vulnerable Adult documentation will be provided to all operational staff This will be completed by
31.01.14_ Recommendation 7 _ Support Services All agencies need to review their service responses to people who suffer Alzheimer's and other Dementia Diseases and their Carers. This should be done in partnership with groups such as the Alzheimers Society who have significant knowledge and understanding of the issues_ Response: MCRT commented that current training delivered to operational staff when dealing with vulnerable aduits deals with mental health issues as a Whole and does not individualise conditions such as Dementia and Alzheimer's_ The recognition of a vulnerable adult by Police Officers and staff is considered sufficient to trigger a referral process for specialised assistance. The tactical equality and diversity advisor has recently attended a Dementia Friends workshop to scope the feasibility of additionai awareness sessions, This is captured within the Warwickshire and West Mercia Mental Health Delivery Plan (action 18) with completion date of 01.09.14 Recommendation 8 _ Support Services A joint working group to be developed involving all agencies to address the increasing prevalence of dementia to identify the manifestation of harm to themselves or others and management plans to address these issues Response: The arrangement of a joint working group will be tasked by the Safer Communities Partnership to the Safeguarding Adults Board. West Mercia Police will ensure full participation from specialist staff from the Protecting Vulnerable People Department Details are currently awaited regarding the date of the first meeting: Conclusion The matters raised as a result of the DHR will be actioned a8 detailed above. This will be monitored until completion and discharged via the Strategic Oversight and Scrutiny Group, chaired by Assistant Chief Constable from